Posts Tagged ‘England’

When you arrived at work this morning, were you worried that a police officer might be waiting for you? Horrible start to the day, that, seeing a uniformed officer blocking your way. Inside, you see other officers taking copies of all your computer files and emails. The officer speaks gently, but firmly. Come with me please. Yes, your manager has been informed. Now, please, if you would.

I really hope this never happens to you. But it could. Because passing through Parliament at the moment is the Care Bill, and it creates new criminal offences that will affect anyone who works with waiting lists or patient coding, including information analysts, clerks, clinicians and managers.

Check it out for yourself. It’s all in Section 81 and there’s plenty of background in the Department of Health’s Impact Assessment (IA).

The proposed offence is to supply false or misleading information, and because this is a criminal offence it involves the police, Crown Prosecution Service and courts. It applies to care providers not individuals, so nobody will go to jail but the fines, remedial orders, and publicity orders will be heavy enough.

We don’t yet know exactly what kinds of information will be covered because those will be specified in regulations, but the IA makes clear that mortality rates and waiting times data are top of the list (and in this post I will deal only with the waiting list aspects). And what if the data error is an honest mistake? It that case “it is a defence for a care provider to prove that it took all reasonable steps and exercised all due diligence to prevent the provision of false or misleading information”.

This is tough stuff. Is it a good thing? Yes. Waiting list data is a clinical safety issue. If patients get lost in the system, then they are at risk. If every report of a long-waiting urgent patient is met with “oh, that must be a data error”, then the genuine cases will not be caught quickly and patients will come to harm. The NHS has tolerated high levels of data error on its waiting lists for its entire existence and it is time that stopped.

But I think the Department of Health is wrong, in its Impact Assessment, to expect that a dozen or so hospitals will face police action every year. That would be a failure: a failure to change the culture of top-down control and punishment, as well as a failure of the local NHS to clean up its data. The purpose of the criminal law is not to performance-manage the bottom 5 per cent of hospitals; it is there to deal with crime. If the police have to bring charges under this section (for waiting list offences) more than once every few years, then that is too many.

What do we need to do, to avoid the drip, drip, drip of regular police investigations and prosecutions? Due diligence, yes, but that is only the means: accurate waiting list data is the end, and we need to keep that end clearly in sight. This is going to be a big but worthwhile job, and it is going to involve hundreds of people in every NHS Trust. If everybody is focused on covering their backs with audit trails (instead of making patient records accurate) then it will all be an expensive waste of time.

Let’s start with the fundamentals. Mainstream administrative records should reflect accurately the real patient journeys that are taking place in the hospital. The patient is referred from outside, waits, is seen by a clinician, is perhaps referred to another clinician (and waits again), and so on until eventually the patient is discharged. Each stage of that pathway may involve a different IT system, and ultimately we want each system to record and report where the patient came from and why, where they went next and why, or (if they haven’t gone anywhere yet) how they are currently being managed.

It’s like a bank account. Every penny is accounted for: where it came from, and where it went, or (if it’s still there) which account it’s in. And the accounting analogy turns out to be very useful, because we can check that our bank statement is correct without having to track every penny individually. All we have to do is look at the inflows and outflows and check that they balance. And we can do exactly the same with waiting lists. It looks like this:

If you do those accounts with the raw data for a typical hospital waiting list, the numbers do not balance. In my experience they are typically out by something like 10 per cent. You wouldn’t tolerate that on your bank statement, and now we need to take the same attitude to our waiting list data. So the first thing you need to do is put somebody in charge of these waiting list “accounts”, somebody for whom any imbalance strikes against their very soul. This is a job for an accountant.

In fact, you’re going to need a lot of the paraphernalia of accountancy: waiting list “accounts” at service level; aggregate accounts at specialty, care group, and Trust level; and auditing systems. But most of all you need to develop a culture that these “accounts” must balance everywhere at all times because, if they are out by just one patient, then that is a patient who might fail to receive the care they need and is therefore at risk.

Commissioners: this involves you too. You may not be covered by the criminal offence (which applies only to care providers) but these are your patients and you need to be sure they are being looked after. So take an interest, work constructively with providers, and write into the contract that they must share with you their detailed waiting list “accounts”. You already make sure the money you send them balances, and it is even more important to do the same with patients.

Yes, this is going to be a lot of work, especially at first. But it’ll be worth it. Here is an opportunity to break the cycle of inspection and punishment, and deliver a valuable goal that has no down-side. The time to start is right now. Then, when the Bill is passed and the offences come into force, Plod and all the inspectors can whistle because you’ve already sorted it out.

And, best of all, you won’t feel anxious every time you see a police car parked outside the hospital.

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PS: I know of at least one hospital that has successfully put an accountant in charge of balancing its waiting list movements. If you’ve done this where you are, or balanced your waiting list “accounts” in another way, please use the comments section over at the HSJ to let everyone know.

Oops. And sorry. I’ve been checking over my figures and found that I made a mistake when adjusting the size of the English waiting list for Trust mergers. It turns out the waiting list has grown more significantly than I originally thought, and is now noticeably higher than in recent years.

I’ll expand on the correction in a moment, but first here is the new estimate of the adjusted waiting list:

As you can see, the size of the English waiting list rose sharply in March and is now seasonally bigger than in recent years. The size of the waiting list is significant because it is an early warning of waiting times pressures building up in the NHS. However it is also worth noting that the increase remains comparable to the amount of variation we have already seen in recent years, so as things stand this is an indicator of rising pressure and not an omen of doom.

For comparison, the unadjusted trend is this:

What is the difference between these two charts?

The unadjusted chart shows the raw figures submitted to the Department of Health (number of incomplete pathways, commissioner basis). The adjusted chart is an attempt to strip out the effects of step changes, for instance when a Trust starts including some waiting list patients who have previously been missing from its data, or when a Trust takes a reporting break to fix a serious problem with its data.

Ideally all the data would be perfect all the time, but in practice it is difficult for NHS Trusts to count all their incomplete pathways, because patients are being managed on so many different IT systems. So it is good that Trusts are continuously improving their data recording (even though it causes awkward shifts in the time trends), and this process will continue because there is still some way to go.

The method I used to detect and strip out these step changes has not changed. What has changed is the further adjustment that needs to be made for Trust abolitions and mergers.

For instance, let’s take the giant merger that formed Barts Health NHS Trust in April 2012.

The three previous Trusts (Barts and The London NHS Trust, Newham University Hospital NHS Trust and Whipps Cross University Hospital NHS Trust) all disappeared from the data series after reporting at the end of March 2012. Only the new Trust exists in the current published waiting list data.

When it is detecting step-changes, my software uses the current data as its to-do list when working back to detect step changes. So it automatically detects the new Trust’s appearance in April 2012 and adjusts for it in previous months, but it doesn’t detect the three prior Trusts that aren’t on its to-do list. So we need to make a further adjustment for the three old Trusts to balance the appearance of the new one. The problem was that I had missed some former Trusts out, and in this example I had taken the old Barts and The London into account, but not Whipp’s Cross or Newham. Hence the need to correct the method now.

So I have trawled back through all the old data, to see which Trusts no longer exist. Those that have disappeared in the last three years (and which are all now included in the calculations) are:

• code RAE: Bradford Teaching Hospitals NHS Foundation Trust (not abolished but on a prolonged ‘reporting break’; last reported in Sept 2012 with 16,332 patients on the waiting list);
• code RBF: Nuffield Orthopaedic Centre NHS Trust (merged into Oxford Radcliffe NHS Trust to form Oxford University Hospitals NHS Trust; last reported in October 2011 with 3,529 patients on the waiting list);
• code RCC: Scarborough and North East Yorkshire Health Care NHS Trust (merged into York Teaching Hospital NHS Foundation Trust; last reported in June 2012 with 8,386 patients on the waiting list);
• code RGC: Whipps Cross University Hospital NHS Trust (merged to form Barts Health NHS Trust; last reported in March 2012 with 13,343 patients on the waiting list);
• code RM4: Trafford Healthcare NHS Trust (merged into Central Manchester University Hospitals NHS Foundation Trust; last reported in March 2012 with 5,943 patients on the waiting list);
• code RN1: Winchester and Eastleigh Healthcare NHS Trust (merged into Basingstoke & North Hampshire NHS Foundation Trust; last reported in December 2011 with 13,245 patients on the waiting list);
• code RNH: Newham University Hospital NHS Trust (merged to form Barts Health NHS Trust; last reported in March 2012 with 7,475 patients on the waiting list);
• code RNJ: Barts and The London NHS Trust (merged to form Barts Health NHS Trust; last reported in March 2012 with 25,994 patients on the waiting list).

The effect of including all these former Trusts has been to change the adjusted chart from the version I reported last week:

to the new estimate of the adjusted position:

Hope it’s all fixed now. Apologies again, and do let me know if you think I am still missing something.

The number of patients on the English waiting list increased sharply in March, according to the latest figures, and the total list size is now larger than in recent years.

There had been speculation that winter bed pressures, which caused cancellations of elective surgery in March and April, would lead to longer waiting lists. But the number of patients admitted from the waiting list was broadly on track in March, so the picture is not quite so neat and rising referral rates are part of the explanation.

The number of patients waiting is an early indicator of waiting times pressures to come, so a rising waiting list is cause for concern. But it takes time for the pressures to feed through. The position on 18 weeks was broadly stable in March with only a small deterioration, and the number of one-year-waiters broke new records as providers clear their extreme long-waiters before the zero-tolerance penalties begin in April. One-year-waiters fell to just 473 at the end of March, down from 665 the previous month and 5,149 the previous year.

All figures come from NHS England, who have taken over responsibility for this data series. If you have a national statistic that you’d like to check up on, you can download our NHS waiting times fact checker

England-wide picture

The officially-reported number of patients waiting (i.e. incomplete pathways) rose sharply, and looks very high. But in recent years the NHS has been improving the coverage of its reporting, so…

If you strip out the effects of step-changes in the data then the list size looks more in line with the last few years. Nevertheless the increase in March has taken it to a new seasonal high which is cause for concern. (The adjustments used in the chart below take into account the return of North Bristol to this data series, which accounted for 27,185 of the increase.)

Admission rates continue to follow the broad pattern of previous years, despite the widely-reported winter pressures. Admissions per working day did fall slightly compared with February, when in previous years they have risen into March, but these figures do not show widespread cancellations on anything like the scale of the very cold winter of 2010.

One-year-waiters have again fallen rapidly, in advance of the zero-tolerance penalties for one-year-waiters which began in April. Other long-wait measures remain broadly steady.

My preferred measure of 18-week-waits, the 92nd centile waiting time for incomplete pathways, remains steady with just a small deterioration.

At specialty level, General Surgery finally tipped across the line to fail narrowly against the target. Orthopaedics continued to deteriorate, as did the more specialised long-wait specialties.

The proportion of services at provider-specialty level remained stable, with just a small decline from 85.2 to 85.1 per cent achieving the incomplete pathways target.

 

Provider top ten

Congratulations to the Robert Jones and Agnes Hunt Orthopaedic Hospital (RJAH) for nearly halving their one-year-waits backlog. They had to admit some 53 one-year-waiters to do this, which was the equal highest number of over-one-year admissions in England.

Trusts with the largest numbers of one-year-waiters remaining are: 79 at East Kent, 57 at King’s, 54 at RJAH, 42 at the Royal Orthopaedic, 39 at Barts, 16 at Doncaster, 16 at Royal Devon, and 13 at Southampton.

As mentioned above, North Bristol have finally restarted submitting waiting list data for the first time since July 2012. Bradford are still absent from this data series.

The April 2013 data is due out at 9:30am on Thursday 20th June 2013.

Here is the local picture on 18 week waits, fully updated with the latest RTT waiting times data just released by NHS England.

If you want to pick an NHS Trust or independent sector provider, or an NHS Commissioner, you can get a full analysis of the pressures in any specialty here.

Where are the very-long waiters?

The following maps compare one-year waits, 18-week waits, and total waits, with the values a year before. The first map shows providers, and the second shows commissioners and is therefore on a population basis.

The provider map shows NHS Trusts only to avoid map clashes with independent sector providers on the same site, but you can download the full data for all providers and specialties at the end of this post. In the map, click a pin to see the detail, then click the organisation  name to get a full analysis.

 

92 per cent of the waiting list within 18 weeks

The most meaningful (and, from April, the main contractual) waiting time measure is that 92 per cent of the waiting list (‘incomplete pathways’) must be within 18 weeks. So these maps shows how long 92 per cent of the waiting list has actually waited.

You can download a table of all the specialty-level detail here: Map-data.xls

I have a puzzle for you: thousands of patients are apparently missing from the English waiting list. I don’t know where they are (though I’ll have a go at guessing), and I’m hoping some of you can help me.

Here’s the problem.

In principle, we should be able to start with, say, the 4-5 week waiters from the end-of-January waiting list, take away those patients who were admitted and non-admitted from the cohort during February, and (because February was exactly 4 weeks long) end up with an estimate of the 8-9 week waiters on the end-of-February waiting list.

That method would miss any patients who were removed without being seen or treated (for instance ‘validated’ patients who had been reported on the January waiting list in error), but that error should all be in one direction: to make the reported February figure smaller than our estimate. Patients cannot appear on the waiting list with several weeks on the clock out of thin air, can they? So our estimate, minus the reported end-of-February list, should always produce an anomaly that is positive and which reflects validation during February.

Sounds great. But if you actually do the sums you come across some oddities. Several, in fact, as you can see from the supposedly-impossible negative values in the chart below.

1) Missing very-short waiters

The first oddity is for the very shortest waiters. If you take the number of patients across England who have waited 1-2 weeks at the end of January, and knock off February’s admitted and non-admitted patients, then the expected number of 5-6 week waiters at the end of February should be no more than about 177,720. But in fact some 179,087 were reported in the end-of-February waiting list data: more than a thousand too many. That’s the small negative anomaly at 5-6 weeks in the chart above. A thousand-odd patients have appeared in the February figures out of thin air. Where did they come from?

They weren’t new referrals being treated immediately (they could only affect February’s 4-5 week cohort, which should really be part of this oddity as well). So they must only have appeared on the waiting list a week after referral. This, as far as I am aware, is quite common, because paper referrals are often graded for urgency by the consultant before being recorded on PAS, and this process can take as long as a week or two. So if that’s the explanation then that would explain the first oddity.

2) Missing 9-week waiters

The second oddity crops up at 8-10 weeks, and this is larger and more mysterious. At the end of January there were 233,003 patients on the waiting list who had waited 4-6 weeks since referral. After deducting the relevant admitted and non-admitted patients, you are left with an upper limit for 8-10 week waiters at the end of February of about 129,045. But in fact the reported figures show there were 144,434: some 15,389 too many, and causing the large negative anomaly in the chart. That’s a lot of patients suddenly appearing in the February figures. Where did they come from?

I don’t know the answer to this one, which is why I’m asking. But my guess is that this has something to do with cancer pathways. Could it be that some cancer patients are not being reported in the incomplete pathways statistics, but are being reported in the admitted and non-admitted figures? The NHS Standard Contract specifies that cancer patients should be treated within 62 days of referral, which is 9 weeks and coincides nearly enough with this anomaly. If large numbers of cancer patients are not being recorded in hospitals’ mainstream computer systems, which this explanation implies, then that in itself could be worrying because parallel and duplicate administrative systems can lead to patients getting lost.

3) Missing 17-week waiters

The third oddity is around 18 week waits. It isn’t large enough to appear as a negative anomaly in the national statistics charted above (though it does show as a step-change), but if you drill down to Trust level it does produce a negative anomaly for some individual Trusts. Because the cohort-tracking sums are inexact, and because quite a few Trusts crop up in this analysis, I am not going to name Trusts individually but instead will look at the overall pattern.

At some Trusts, the reported number of patients waiting 17-18 weeks at the end of February is higher than you would expect (a negative anomaly at Trust level), and they have no negative anomaly for 18-19 week waiters. In most cases the negative anomaly is small (or a small percentage). But in a handful of Trusts it does look significant; in other words significantly more patients are being reported just within the 18-week target than you would expect.

Again I don’t know what the explanation is, but my guess is that some Trusts (or some parts of some Trusts) might be applying clock pauses to their waiting list figures. That is strictly forbidden; the guidance says (emphasis in original):

“Clock pauses may be applied to incomplete/open pathways locally – to aid good waiting list management and to ensure patients are treated in order of clinical priority – however, adjustments must not be applied to either non-admitted or incomplete pathways RTT data reported in monthly RTT returns to the Department of Health.“

4) Disappearing 18-week breaches

The final oddity is just above the 18-week mark, and this anomaly goes in the opposite direction. From 18-22 weeks, the end-of-February waiting list is around half the expected size, so the anomaly is much more positive than expected.

My guess is that this is the result of waiting list validation being targeted at over-18-week waiters so that they don’t score against the admitted and non-admitted standards. This is a largely redundant tactic now that the main focus of the penalties, from April, is on incomplete pathways; Trusts today would be better advised to focus their validation efforts on patients approaching 18 weeks, rather than those who have already breached.

So there are four oddities in the data. If you can help explain any of them, or at least explain what is happening where you work, then do leave a comment below this post on the HSJ website (either anonymously or otherwise), or contact me in confidence by email or publicly on Twitter.

If you want to dive into the figures, you can download a spreadsheet that contains all the detailed calculations here.

POSTSCRIPT

A few more suggestions that have been put to me since I posted this:

Some missing waiters around the nine-week mark could be Choose & Book patients, who were told by C&B that no appointments were available and therefore raised an ASI (Appointment Slot Issue). Those patients might then be managed on paper by the hospital until their slot is arranged, which might take several weeks, during which they might not be reported as incomplete pathways. (Incidentally, this is a wasteful and risky administrative process, and the patient usually ends up in a similarly-dated slot to the one they would have had if C&B polling ranges had simply been extended.)

Some missing patients close to the 18-week mark at Trust level (though not at national level) are tertiary referrals. These arrive at the tertiary centre with time already on the clock (although there is now the option for the referring provider to take the ‘hit’ on any breaches caused by delays at their end: http://transparency.dh.gov.uk/files/2012/06/RTT-Reporting-patients-who-transfer-between-NHS-Trusts.pdf).

Here is a comment left at the HSJ website:

Anonymous | 2-May-2013 11:13 am

A few points come to mind in response to this article:
- As a general comment, early this (calendar) year, the impending financial penalties for >52 week waiters resulted in a flurry of activity to clear up waiting lists and address data quality issues. This almost certainly has created lots of apparent anomalies that are in fact data quality corrections.
- The >52 week penalties are contained in the standard NHS contract template – you will find that some CCGs have chosen not to include them in the final versions used for their providers. I think this may happen in situations where the provider is on a block contract. This is probably not a major factor though.
- My experience suggests that providers will not stop validating 18 week breaches against the clock stop targets – I am not sure any board or exec would simply not be worried about breaches that aren’t really breaches, financial penalty or not. It is still a core operational standard (as defined by the NTDA) so will still create a fuss if not achieved.
- as regards the missing very short waiters, grading for urgency by clinicans has definitley been known to take longer than 2 weeks. A less than one percent discrepancy could easily be explained by late grading and, probably more commonly, hospitals without single points of referral receipt not getting things on the system ina timely fashion e.g. letters going directly to med secs who sit on them for too long. If you know the patient won’t be seen for >10 weeks, why bother getting them on the system – this is the attitude in some cases at least!

February saw a further 21 per cent fall in the number of patients waiting over a year in England, hot on the heels of a 22 per cent fall in January. Across the country there were only 665 one-year-waiters at the end of February, down a massive 88 per cent from 5,653 a year earlier. For the first time ever, no provider had more than 100 one-year-waiters on its waiting list.

Providers are under pressure to treat their one-year-waiters because, starting with the end of April figures, they face ‘zero tolerance’ fines of £5,000 per patient per month if they report anyone still waiting more than 52 weeks after referral.

The position on 18 week waits was broadly stable, with 92 per cent of the list waiting up to 16.4 weeks and comfortably achieving the 18 week target at national level. The total size of waiting list, if you strip out step-changes, was broadly in line with the seasonal profile of previous years.

All figures come from NHS England, who have taken over responsibility for this data series. If you have a national statistic that you’d like to check up on, you can download our NHS waiting times fact checker

One more thing before we move on to the detail. You wait ages for a review of NHS waiting times and then two come along at once. These things really don’t happen very often (about once a decade) so if you have anything on your mind about how waiting times are measured then feel free to respond to the consultations by the National Audit Office and UK Statistics Authority.

England-wide picture

On the raw figures, the waiting list looks high for the time of year:

But if you strip step-changes out of the data (using the method explained here) then it doesn’t look out of line with previous years.

Admission rates continue to follow the pattern of previous years, despite the difficult winter.

One-year-waiters continue to fall rapidly, and we can expect even more dramatic reductions in the next couple of months as the zero-tolerance target comes in. Other long-wait measures remain steady.

My preferred measure of 18-week-waits, the 92nd centile waiting time for incomplete pathways, is holding steady.

Drilling down to specialty level, there is continued deterioration in orthopaedics and plastics, and in the more specialised services of neurosurgery and cardiothoracic surgery. General surgery has just scraped inside the 18 week target for another month.

The target must be met by every specialty in every provider in every month, and 85.2 per cent are succeeding, which is broadly stable from previous months.

Provider top ten

RJAH still has the longest ’92 per cent’ waiting times, and has the most one-year-waiters, but has gained some ground since the end of January. At number 2, Clinicenta have not improved their ’92 per cent’ waits, but they have cleared all their one-year waiters.

For the first time, no provider has more than 100 one-year-waiters on its waiting list. Those with the most are:  RJAH 98, Kings 73, Guys/St Thomas 44, East Kent 42, Royal Orthopaedic 35, Western Sussex 27, Brighton and Sussex 26, Southampton 26. Some 62 Trusts reported any one-year-waiters, down from 64 in January.

North Bristol and Bradford still aren’t submitting incomplete pathways data. North Bristol last submitted in July 2012, and Bradford in September 2012.

One provider dropped out of the top ten: congratulations to North Cumbria, whose improvement on ’92 per cent’ waits from 18.3 to 17.8 weeks has earned them a drop in the table from 10th to 34th place.

The 12-month statistics calendar has also moved to NHS England. The next figures (for the end of March 2013) are expected at 9:30am on Thursday 16 May 2013.

Here is the local picture on 18 week waits, fully updated with the latest RTT waiting times data just released by NHS England.

If you want to pick a Trust or independent sector provider, and get a full analysis of the pressures in any specialty, then all the detail is here. I’m afraid haven’t put the PCTs up this time because I had a software glitch overnight (and am hoping nobody will mind because they’ve all been abolished now anyway).

Where are the very-long waiters?

The following map compares one-year waits, 18-week waits, and total waits, with the values a year before. You can click the provider name to get a full analysis.

92 per cent of the waiting list within 18 weeks

The most meaningful (and, from April, the main contractual) waiting time measure is that 92 per cent of the waiting list (‘incomplete pathways’) must be within 18 weeks. So this map series shows how long 92 per cent of the waiting list has actually waited.

Unfortunately the mapping service I use has limited their free service to 250 lines of data, so I can’t map the specialty-level data any more. But you can download a table of all the detail here: map data

Official statistics aren’t perfect, and that goes for the waiting list too. Sometimes Trusts discover waiting lists that they should have been reporting, but weren’t. Sometimes they find problems with their data, take a ‘reporting break’ for a while, and then resume on a different basis. And data can also be discontinuous when Trusts are abolished and created, or when services shut down or move.

So stuff happens, and it all affects the reported number of patients on the waiting list. The question is: when you add up all these changes, could they explain the apparent growth in the English waiting list? Funnily enough it turns out that, yes, they could.

Here is the officially-reported number of patients on the English waiting list (count of incomplete pathways) since the 18-week target was achieved ‘properly’ in summer 2009. You may recognise this chart from my monthly reports on waiting times in England, and as you can see the red line is looking high for the time of year.

But if you trawl through all the detail at Trust-specialty level, and strip out any apparent step-changes in counting, the chart looks like this instead:

As if by magic, the increase has disappeared. It isn’t proof, but it’s enough to cast serious doubt on the apparent increase, and I think we can all be more relaxed about it. After adjustment, the size of the waiting list looks pretty stable year after year, and any increases and decreases are lost in the noise without any discernible trend.

Method

You may be feeling sceptical at this point, which is perfectly reasonable. So now I’ll explain exactly how I adjusted the official figures to produce the second chart, and you can make your own mind up about the conclusions.

Fans of statistical process control may be thinking of 3-sigma variations or CUSUM charting at this point, but the problem with those methods is that they all rely on deviations from an intended or mean central value. But the size of a waiting list does not have a central value, so we need to use a different approach. Instead I applied two rules to detect steps that may be caused by counting changes; either:

1) the reported list size falls to zero, or rises from zero, which should detect new or closed services and ‘reporting holidays’; or

2) the average of the next 4 months differs from the average of the previous 4 months by more than 2 standard deviations (where standard deviation is measured month by month over the whole time series), which should detect ‘newly-discovered’ waiting lists and major validation exercises.

The two tests were applied month by month to list size data from August 2009 to January 2013, at Trust-specialty level, which is the most granular data publicly available and therefore gives the best chance of detecting service-level changes. Steps in the data were detected in 2.4 per cent of months, which is equivalent to a step-change every 3.5 years at Trust-specialty level.

The data trawl was based on the current list of Trusts, so further adjustments were made for Trusts who existed in the March 2012 data but not the following month (principally pre-merger Barts). No Trusts disappeared from the data series in the month following March 2011 or March 2010.

If you have ever tried to detect anomalous deviations in time series data, you will know how frustrating it is. Sometimes your eye tells you there is a screaming change in the data, but your formula doesn’t pick it up. Other times your formula picks up a deviation that your eye tells you is just noise. The eye is very good at pattern-recognition, but it is also subjective, easily-led, and gets tired. So with 2,622 Trust-specialties to trawl, it’s better to let the computer do the work and hope the errors come out in the wash.

Let’s take a look at some examples of steps detected by the two rules. In each chart, the blue line is the list size (count of incomplete pathways) for one specialty in one Trust, and the yellow column indicates where a step up or down has been detected by the rules.

Here is a new Trust coming into existence:

Here the size of waiting list steps up, perhaps after the Trust discovered an unrecorded waiting list:

In this one, a Trust discovered a problem with its waiting list data, took a ‘reporting holiday’, and resumed reporting with corrected data:

I mentioned that sometimes the eyeball and the computer disagree with each other, and here are a couple of examples. Firstly, here is an example where the computer detected a step but the eyeball says it’s just noise:

And here is some data where the eyeball says this is a service that is being progressively shut down. The algorithm, however, doesn’t detect the early stages of the closure because the standard deviation is so high that the steps don’t exceed the two-sigma threshold, and only the final closure down to zero is detected.

To end the examples on a positive, here is some noisy data where no steps are detected by either the computer or the eyeball.

Whenever a step is detected, the later data is assumed to be correct, and all months prior to the step are adjusted by the size of the step. For instance, if the waiting list steps-up by 1,000 patients in June 2011, then all months prior to June 2011 are adjusted by adding 1,000 patients.

The total size of the adjustments across all Trusts and specialties is:

The adjustments made are shown by the green line and, as we saw, they are enough to put the waiting list on the same path as in previous years. Given that the total list size is a decent leading indicator of long-wait pressures feeding through, that would indicate that (at least so far) pressure is not building on the waiting list itself.

The constant caveat, of course, is that the list size does not tell the whole story because referral restrictions may be holding up patients before they get that far.

UPDATE: This methodology is now incorporated into my regular monthly analysis of the English waiting list, with a couple of differences. Firstly, independent sector providers will be included. Secondly, hospitals admitting fewer than 50 patients in the most recent month will be excluded. The overall conclusions remain the same despite the changes.

Just before Christmas the new ‘zero tolerance’ penalties for one-year waiters were announced. From April, any provider reporting one-year-waiters on their waiting lists will be fined £5,000 for each patient, every month.

That’s pretty hefty, and you might expect providers to respond by trying to clear their one-year-waiters before the penalties kick in. These latest figures are for January, so they come only a few weeks after the penalties were announced and perhaps it is early days. Yes, one-year-waits came down, but this was really just a continuation of the reductions that started back in the summer of 2011.

Meanwhile, the over-18-week waiting list is treading water with just a small (possibly seasonal) deterioration in January.

Underlying it all, the total size of the waiting list remains high for the time of year, and the gap over previous years is still growing. Some of the increase may be caused by providers improving their record-keeping as the waiting-list-based targets phase in, and I’ll be looking into this shortly to see if we can quantify that effect.

All the statistics used in this analysis are published by the Department of Health, and you can download a fact-checker with all the time series here: NHS waiting times fact checker

England-wide picture

The total number of patients on the waiting list is looking increasingly high for the time of year.

Admissions are still bang on trend.

The welcome reduction has continued in the number of patients waiting more than a year after referral. No sign, yet, of an acceleration before the zero-tolerance penalties kick in.

From April the main target will be that 92 per cent of patients on the waiting list must be within 18 weeks of referral. At national level this is still being met comfortably.

Dig a little deeper, to specialty level, and we see that long-wait specialties have been deteriorating since the start of winter. Among the big surgical specialties, Orthopaedics continues to drift away from target, and General Surgery is now flirting with failure.

The new main target from April, that 92 per cent of the waiting list must be within 18 weeks, must be met in every specialty in every provider in every month. At the end of January, 86.1 per cent of provider-specialties were succeeding and this (like the other 18-week indicators) has remained steady.

Provider top ten

RJAH tops the list again, and its reported long-wait position is even worse than in December (when 92% of the waiting list was within 36.5 weeks, and there were 97 one-year-waiters). Despite having the worst waiting lists in England, they still managed to achieve the current headline target by choosing 90.1 per cent of their admitted patients from the short-waiting end of their waiting list. This is a (very nice, and popular) specialist orthopaedics hospital and it is possible that their very-long-waiters are concentrated in one sub-specialty. (In orthopaedics it is, for instance, common to find particular pressure in spinal surgery.) Still, though.

In the number 2 slot, Clinicenta are reporting far fewer one-year-waiters (they had 26 at the end of December).

The Trusts with the largest numbers of one-year-waiters are RJAH with 119, King’s 118, Guys/StThomas 63, Nottingham 59, Newcastle 39, Royal Orthopaedic 38, West Sussex 38, and Brighton 35. Some 64 Trusts reported any one-year-waiters, which is a small improvement from 66 Trusts in December.

North Bristol and Bradford still aren’t submitting incomplete pathways data.

Congratulations to those providers who dropped out of the table since last month, with 92nd centile incomplete pathway waits falling from: 18.2 weeks to 17.5 weeks at Nuffield Health, Leeds Hospital; from 18.9 to 17.9 at Doncaster and Bassetlaw Hospitals NHS Foundation Trust; and from 18.0 to 17.2 at Southport and Ormskirk Hospital NHS Trust.

The 18-week statistics for February 2013 are due out at 9:30am on Thursday 18 April 2013.

Here is the local picture on 18 week waits, fully updated with the latest RTT waiting times data just released by the Department of Health for England. For an overview of referral-to-treatment waiting times in England see the parallel post here.

If you want to pick a Trust, independent sector provider, or PCT, and get a full analysis of the pressures in any specialty, then all the detail is here.

Where are the very-long waiters?

One-year-waiters are continuing their steady improvement, and there are only 842 left. This should come down more rapidly now, in advance of the ‘zero tolerance’ penalty which starts in April.

The following map compares one-year waits, 18-week waits, and total waits, with the values a year before. You can click the Trust name to get a full analysis.

Other maps you might find useful:
All specialties together, by NHS/IS provider (same as map above)
Each specialty separately, by NHS/IS provider
All specialties together, by PCT (i.e. population basis)
Each specialty separately, by PCT

92 per cent of the waiting list within 18 weeks

The most meaningful (and, from April, the main contractual) waiting time measure is that 92 per cent of the waiting list (‘incomplete pathways’) must be within 18 weeks. So this map series shows how long 92 per cent of the waiting list has actually waited.

Each specialty separately, by NHS/IS provider
Each specialty separately, by PCT (population basis)